Hyperthyroidism

1. Hyperthyroidism Shannon Galey University of South Florida Med Surg 1

2. Thyroid Functions • Hormones of the thyroid gland T3 and T4 produce and regulate adrenaline, epinephrine, dopamine • T3 and T4 are crucial for brain development • Also regulates metabolism • Works hand in hand with pituitary gland to produce TSH ( pituitary gland controls the amount of TSH released to the body) • Thyroid can be considered the “manager” of the body • Regulates all body organs and functions

3. Hyperthyroidism is a disorder that involves the excess secretions of thyroid hormones by the thyroid gland, this can lead to a hyper metabolic condition called thyrotoxicosis. The most common forms of hyperthyroidism are graves disease, Plummer disease, (Toxic multinodulargoiter) and toxic adenoma. Pathophysiology

4. Graves Disease Diffuse enlargement of both thyroid lobes, with uniform uptake of isotope and elevated radioactive iodine uptake 60-80% of all cases of Hyperthyroidism in the US Peak occurrence in people aged 20-40 years old

5. Toxic multi nodular goiter“Plummer Disease” Irregular areas of relatively diminished and occasionally increased uptake; overall radioactive iodine uptake is mildly to moderately increased 15-20% of all hyperthyroidism cases Occurs more commonly in places with iodine deficiencies US adds Iodine to foods so we have less “Plummer disease” then other countries

6. toxic adenoma 3-5% of all hyperthyroidism cases growth of a thyroid nodule that produces and secretes excess amounts of thyroid Many times this nodule may be benign

7. Who gets hyperthyroid While seen in both men and women, it is more common in women A persons chance increases with age presents typically from ages 20-40 years old. Reoccurring pregnancies can lead to thyroiditis which puts younger women at risk for Hyperthyroidism. Hyperthyroidism is one of the most frequently encountered condition in endocrinology Out of three forms of hyperthyroidism, Graves disease is the most common. 25 million people Caucasians and Hispanics are more at risk then African Americans

8. Dangers Of Hyperthyroidism Preterm labor Pregnancy induced hypertension Eclampsia (one or more convulsions in women during pregnancy whom suffer from high blood pressure. Thyroid storm (is a life-threatening health condition that is associated with untreated or undertreated hyperthyroidism. During thyroid storm, an individual’s heart rate, blood pressure, and body temperature can soar to dangerously high levels. Without prompt, aggressive treatment, thyroid storm is often FATAL Heart Failure

9. Treatments for Hyperthyroidsim • Radioactive Iodine (RIA) • Pts whom have been on medication for at least 6 months who have seen no improvement • 550 MBq does of radio active iodine is administered • Majority of the time kills thyroid and pt becomes hypothyroid, or the thyroid will return to normal • Medications • Propylthiouracil • Methimazole • Anti thyroid drugs, they work by blocking thyroids ability to produce thyroid hormone

10. Dietary Modifications • Broccoli • Brussel sprouts • Cabbage • Cauliflower • Kale • Mustard greens • Peaches • Pears • Rutabagas • Soybeans • Spinach • Turnips All of these foods help suppress thyroid function Can be used with daily medications

11. Symptoms Nervousness Anxiety Increased Perspiration Heat Intolerance Hyperactivity Heart Palpitations

12. Signs Tachycardia and atrial arrhythmia Cardiac Output can be 50-300% higher in hyperthyroid pt. Systolic hypertension Warm, moist and smooth skin Lid lag Fixed stare Hand tremors Muscle weakness Weight loss despite increased appetite Reduction in menstrual flow or oligomenorrhea Diarrhea

13. Clinical Presentation can Vary Younger patients exhibit sympathetic activation (anxiety, hyper activity and tremors) Older patients exhibit cardiovascular symptoms (dyspnea, atrial fibrillation) and weight loss Patients with Graves disease often have more “marked” symptoms then patients with other forms Opthalmopathy (periorbital edema, diplopia or proptosis) may indicate Graves disease

14. Diagnostic Tests and Labs Thyroid Function Test Thyroid Function Studies • Thyroid Stimulating Hormone (TSH) • Free Thyroxine (FT4) • Total Triodothyronine (T3) • Thyrotoxicosis is marked by suppressed TSH levels and elevated T3 and T4levels • Patients with milder thyrotoxicosis may have elevation of T3 levels only • Subclinical hyperthyroidism features decreased TSH and normal T3 and T4 levels

15. Diagnostic test and Labs Continued Autoantibody tests for hyperthyroidism Autoantibody titers in hyperthyroidism • Anti ̶ thyroid peroxidase (anti-TPO) antibody • Thyroid-stimulating immunoglobulin (TSI) • Graves disease – Significantly elevated anti-TPO, elevated TSI • Toxic multinodular goiter- Low or absent anti-TPO • Toxic adenoma – Low or absent anti-TPO • Patients without active thyroid disease may have mildly positive anti-TPO

16. Prognosis Stabilization of thyroid function (with meds) Radio active Iodine is recommended(hypo is much safer!) If thyroid ablation totally kills thyroid patient receives thyroid replacement drugs (Synthroid) Thyroid Hormone causes excess left ventricle thickening (heart failure or death) Hyperthyroidism has also been linked to dilated cardiomyopathy and pulmonary hypertension. Graves Disease patients should be concerned with eye disorders and should be checked regularly All Hyperthyroid patients should be monitored regularly and have blood work every 3-6 months

17. Nursing Diagnosis • Activity intolerance r/t increased oxygen need due to increased metabolic rate • Anxiety r/t increased stimulation, loss of control • Diarrhea r/t gastric mobility • Ineffective health maintenance r/t deficient knowledge regarding medications, and coping with stress • Insomnia r/t anxiety, excessive sympathetic discharge • Imbalanced nutrition r/t less then body requirements r/t increased metabolic rate and increased gastrointestinal activity • Risk for injury r/t eye disorders or injuries

18. Nursing Interventions • Energy Management • Exercise therapy • Nutritional Management • Medication Management • Stress Reduction • Assessment of Vital Signs • Education on disorder and Medications • Reporting any changes in signs or symptoms to doctor

19. A patient is admitted to the hospital in thyrotoxic crisis (thyroid Storm). On physical assessment of the patient the nurse would expect to find? • A) Hoarseness and laryngeal stridor • B) Bulging eyeballs and arrhythmias • C) Elevated temperature and heart failure • D) Lethargy progressing suddenly to impairment of consciousness

20. Rationale • The Answer is C : Elevated temperature and signs of heart failure • A hyperthyroid crisis results in marked manifestations of hyperthyroidism, with fever tachycardia, heart failure, shock, hyperthermia, agitation, delirium, and coma. Although exophthalmos (abnormal bulging of eyeballs) may be present in the patient with Graves' disease, it is not a significant factor in hyperthyroid crisis. Hoarseness and laryngeal stridor are characteristic of hypoparathyroidism, and lethargy progressing to coma is characteristic of myxedema coma, a complication of hypothyroidism.

21. Secretion of thyroid Stimulating Hormone (TSH) by which of the following glands controls the rate at which the thyroid hormone is released? • Adrenal Gland • B) Pituitary Gland • C) Parathyroid Gland • D) Thyroid Gland

22. Rationale • The Answer is B : The Pituitary Gland • By secretion of TSH the pituitary gland controls the amount of thyroid hormone released. The adrenal gland is not involved with the thyroid gland. The parathyroid gland only secretes parathyroid hormones and influences calcium, depending on the amount of calcium and phosphorus in the blood. The thyroid gland secretes thyroid hormone but does not control the mount released.

23. Which of the following group of symptoms would you expect to find in an elderly patient with Hyperthyroidism? • Weight loss , Dyspnea and atrial fibrillation • B) palpitations, heat intolerance and irritability • C) Cold intolerance and weight gain • D) Numbness, cramping and tingling of extremities

24. Rationale • The Answer is A : Weight loss, dyspnea and A fib • Most elderly people present with weight loss, A fib and dyspnea. While heat intolerance, palpations and irritability can be seen in younger patients with hyperthyroidism. Cold intolerance, weight gain, numbness and tingling of extremities are typically associated with Hypothyroidism.

25. Citations • Balch, Phyllis A. “Part Two – The Disorders. “ Prescription for Nutritional Healing. By James F. Balch. 2nded. Garden City Park: Avery Group, 1997.331-32. Print. • Iglesias, P., O. Devora, J. Garcia, P. Tajada, and Diez. “Severe Hyperthyroidisim: Aetiology, Clinical • Features and Treatment Outcome. “Clinical Endocrinology 72 (2010): 551-57. Print. • Khalid, Y.,D.M. Barton, V. Baskar, P. Jones, T.E.T. West, and H.N. Buch. “Efficacy of Fixed High Dose • Radioiodine Therapy for Hyperthyroidism- A 14 year experience. “Britiish Journal of Medical • Practitioners. 4.3 (2011): 7-11 print. • Leuwan, Suchaya, PatomChakkabut, and TheeraTongsong. “Outcomes of Pregnancy Complicated • with Hypothyroidism”. Materno-Fetal Medicine (2010): 1-6. Print. • Nabbot, Lara, and Richard Robbins. “The Cardiovascular Effects of Hyperthyroidism.” Methodist • DeBakey Cardiovascular Journal 5.2 (2010): 3. Print. • Ackley, Ladwig. Nursing Diagnosis Handbook. “An Evidenced-Based Guide to Planning Care. 9th ed. • St. Louis: Elsevier Inc, 2011. 58-59. Print. .